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r � <br /> � `s{] <br /> �;� . azardous Waste <br /> i, Stora <br /> c ti b4 A% DATE INSPECTED: �e inspection Form <br /> E " b BANFIELD REPRESE 8anreId Pet Hospital# <br /> it <br /> NTATiVE:(print): <br /> Y[• CONTAINERSSIGNATURE: <br /> Labeled as Hospital <br /> 4S , ,•:v (indicate if present Contents -' <br /> t �.. ) Hazardous Number! Accumulation <br /> s Waste(YIN?) Address noted?YIN? (1M?) Start Date CONDITION CAPSIL <br /> lbsExpired Pharmaceuticals (godlcrackedletc,) SEALED Of Was a Gram Stain Leaking?(YIN?) <br /> Waste Pharmaceuticals <br /> Select States on, <br /> y Waste F y y y y <br /> ormalin <br /> FACILITY Y /] <br /> 5PILL/LEAKlST01IN FOUN <br /> RECORDS <br /> STERICYCLE MA ° FIRST qID KIT PRESEN es a) SPILL SUPPLIES P <br /> IYIFl;STS(in Safe RESENT?(Yes/ o) <br /> DATEt! Binde (Yes! o) <br /> IN5PECTICIN REPORTS(in Safetyginder es! o) <br /> COMMENTS I CORRECTIVE ACTION 1 DISCREPANCY, <br /> if you answered"Yes"to SpillslLeaks and/or" <br /> Conract Ster7 cle direttI Noy.to any of the other items above.or INITIALS <br /> at Banfeld Shar slnc.r�m{pr labels,containers,and di r In. and�on of the container is made <br /> e;s DATE INSPECTED: RANFIELD mail HSE Banfie�for ar <br /> quote,Please prs or <br /> instance on on d issue and how][was resolved. <br /> �t REPRESENTATIVE:(print): eneral uesdonsorassistance <br /> - <br /> SIGNATURFc <br /> CONTAINERS Labeled as Hospital <br /> (indicate if present) Hazardous Number) Contents Accumulation <br /> Waste(YIN?) Address noted? Start Date CONDITION CAPSILIDS <br /> Expired Pharmaceuticals IN? (YIN?) (YIN?) (good/crackedletc.) SEALED Leakin v <br /> (YIN?) <br /> g (YIN? <br /> Waste Gram Stain <br /> Waste Pharmaceutical <br /> Select States Onl <br /> Waste Formalin <br /> FACILITY SPILL/LEAK/STAIN FOUND? <br /> (Yes/Nal FIRST AID KIT PRESENT?(YeslNo} SPILL SUPPLIES PRESENT?(Yes/No) <br /> RECORDS STERICYCLE MANIFESTS(in Safety Binder)(Yes!N) SFI <br /> j DATE IN <br /> COMMENTS!CORRECTIVE ACTION I DISCREPANC <br /> if you answered"Yes"to Spills/Leaks and/or"No"to any of the other items above,or the conditeon of the container is inadequate,p <br /> Contact Steric de direct) at Bonfield Shar slnc.com for labels.rnn i-- ....a a:_____r <br />